All citations for Sixteen Acres Health and Rehabilitation Center LLC
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
December 9, 2025
Showing 1 to 25 of 28 citations
No harm, with potential for more than minimal harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Assure that each resident’s assessment is updated at least once every 3 months.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
The home gave a date the problem would be corrected (January 20, 2026).
No harm, with potential for more than minimal harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The home gave a date the problem would be corrected (October 5, 2024).
No harm, with potential for more than minimal harm
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
The home gave a date the problem would be corrected (October 5, 2024).
No harm, with potential for more than minimal harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
The home gave a date the problem would be corrected (October 5, 2024).
No harm, with potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
The home gave a date the problem would be corrected (October 5, 2024).
No harm, with potential for more than minimal harm
Assess the resident when there is a significant change in condition
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
PASARR screening for Mental disorders or Intellectual Disabilities
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Provide activities to meet all resident's needs.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Provide care or services that was trauma informed and/or culturally competent.
The home gave a date the problem would be corrected (July 7, 2023).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
The home gave a date the problem would be corrected (July 7, 2023).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.